It has been 3 months since we began using blunt cannulas for filler injections. I wish I could forget the needles all together! There is no reason to subject my patients to the risk of bruising or bleeding if a better and safer alternative is available.

The needle-less filler injection is the single most monumental change that has occurred in the field of dermal fillers in several years; it has spread throughout Europe and South America very rapidly since it’s introduction less than 2 years ago. Aesthetic physicians around the world have embraced this chance to make filler injection strikingly less unpleasant and cut the risk of bleeding and bruising to almost negligible!

There seems to be another advantage of using cannulas. If placed properly and in a particular fashion the metabolism of the product could be delayed and the filler may last much longer!

The concept of a no-needle technique is not a new idea; it has been used for fat transfer for quite some time. Yet, the use of cannulas for dermal filler placement is hardly known in this country; even the representatives of filler companies are not familiar with this concept. It is somewhat puzzling since the reps from the same companies in South America or Europe are well versed in this technique and share all necessary information with their physicians. They are instrumental in helping their doctors to attain the necessary skills and equipment; both as a free addition to the purchased fillers.

The main problem is the availability of the cannulas, the blunt “needles” necessary for the injection of fillers.

Since the procedure is quite new, there are very few committed dermal filler cannula manufacturers around the world, however they work closely with the manufacturers of dermal fillers. Their products are available in several sizes and various lengths. These companies have grown exponentially within the last 12 months due to the enormous popularity of this technique and the continuously growing demand.

Overall, the no-needle injection technique is a major step forward in Aesthetic Medicine making filler injections a procedure that is much safer, less traumatic and with negligible downtime. There are reports of a longer duration of these dermal fillers when injected through a cannula.

There are only 4 centers in the US who use cannulas; two of them use this technique for lips only. We are very proud to be one of only two centers in the USA using this technique for total facial aesthetics.

PART  V

Mistakes in comprehension of artistic structure are easily made when an unaware practitioner judges his task within very narrow limits rather than taking into account the overall structure. The local situation may suggest one concept but the total context may demand another. In facial aesthetics the whole is almost always greater than the sum of its parts. The incapacity to grasp a pattern as a whole is a clinical condition called visual agnosis. The above applies most visibly in facial reconstruction from facelift through enhancements with dermal fillers to the effect of botulinum toxin. All through the process of  reconstruction, the able practitioner must bear in mind the structural skeleton he/she is shaping while at the same time must pay attention to the quite different contours, surfaces and volumes that are actually being made. The guiding image in the artist’s mind is not so much a faithful preview of what the completed work will look like, but mainly the structural skeleton, the configuration of visual forces that determines the character of the visual object.

PART  III

The form of created object is a visible image and shape of the content.  Art itself aims at a graceful but deceitful illusion of reality, and any deviation from reality must be  either avoided, excused  or justified.  If the final outcome fails to fit this concept it is a result of one of the following:

–  the practitioner lacks the skill to accomplish the task,

–  the practitioner depicts what he knows rather than what he sees,

–  the practitioner blindly adopts the pictorial conventions of his peers,

–  the practitioner applies the correct principle from an abnormal point of view,

–  the practitioner perceives wrongly because of defects in his eyes or central nervous system defined as visual agnosis,

–  the practitioner deliberately violates the rules of correct representation

The inability to understand the perception, with results similar to naive realism style, assumes that there is no difference between the object and it’s image perceived by the mind so the mind sees the object itself. This simplified but erroneous concept is then introduced into creative process reducing it to a stiff template… a standardized plastic surgery based on physical data, measurements and ratios. This approach can not bring aesthetic results.

As a practical example a recent report revealed that 21% of all rhinoplasties (nose jobs) are…corrections of badly done nose jobs!

21%! 1 in 5 patients had their noses done by someone with defective aesthetic perception or poor skills. Would 21% failure be tolerated in any non-cosmetic surgical procedures, eg. open heart surgery, gallbladder surgery or removal of tonsils?  Similar results were recently reported on breast augmentation results. No need for comments here.

The major trend in most aesthetic procedures is a drive toward the least invasive procedures. More invasive procedures remain, and should remain, within surgical specialty. These require full surgical training and results are frequently more permanent.

Sadly, the completion of Plastic Surgery training does not depend on any comprehensive understanding of artistic/aesthetic perception or familiarity with the art form. The training should, at least, make them aware of any potential deficiencies that might be a source of aesthetic mistakes in real practice.

If Plastic Surgery training has minimal exposure to true aesthetics, other specialties have no exposure at all. From that point of view, in general terms, only Plastic Surgery training brings licensed physician a bit closer to the artistic understanding necessary in Aesthetic Medicine.

There are exceptions to this rule. I know personally a Plastic Surgeon who is an artist…a virtuoso of his trade. He works on many international celebrities without leaving a trace of enhancements and  remaining conservative in his approach.  Moreover, he is constantly perfecting a non-surgical and minimally invasive approach to many aesthetic problems creating masterpieces with various fillers and botulinum toxin.

I’m sure there are more Plastic Surgeons like him. I hope.

The non-invasive and minimally invasive procedures such as injectable dermal fillers, botulinum toxin, laser and light procedures are relatively uncomplicated in nature but require, like all human tasks, certain amount of knowledge, training and practice. They MUST, contain the same key ingredient: the aesthetic understanding of the art form. Without it, the optimal results are simply impossible regardless of the medical specialty, training, certifications or marketing claims. It is simple as that.

Sadly, the training courses teach a bare minimum necessary to…obtain a certificate allowing it’s holders to practice the “aesthetic medicine”.

The time has come to look at Aesthetic Medicine from a different point of view.

Let’s discuss the meaning of aesthetics, what has become of it, what it should be and what it could be. I begin with my views on facial aesthetics since this is the key element of the most common misconceptions.

Later in this series of comments, I will try address the endless and ever-changing list of aesthetic procedures, particularly those with claims that do not meet promised results.

PART  I

Aesthetic Medicine in the US is beginning to transform. It is a painfully slow process that is, to no surprise, not very enthusiastically welcome by some.

Thankfully, the strong winds of change come from the most important source – the patients!

To me it is a clear signal that the “old school” of facial aesthetics is on the way out; permanently, I hope.  If this is true, it will allow us to join the rest of the world of aesthetics, a world that has been light years ahead of us in using medical aesthetic procedures responsibly.

   The issue of monumental importance in Aesthetic Medicine is the perception, understanding and implementation of true aesthetics – an art form that governs any artistic creation. I am not unique in observing, that too many facial aesthetic procedures have been unsuccessful …they are aesthetic failures. I stress the word “aesthetic” since this is the main ingredient that makes the final result of ANY artistic creation, a great success or miserable failure.

The word “aesthetic” means, in general, the art; the nature of art, it’s philosophy, theory and practice. In contains both, the strict rules and their liberal applications as we hear in music and see in visual arts. Tracing these elements from ancient times until present, all original and revolutionary styles that were breakthroughs of their times, share the basics of the art form. The same must be expected from Aesthetic Medicine if we insist on using this name.

  Aesthetic Medicine has its roots in antiquity with a simple human desire to maintain and improve ones appearance. It evolved into Plastic Surgery which has become almost synonymous with the most sophisticated methods of aesthetic improvements.

   Organized Aesthetic Medicine was born in early 80’s in France and quickly spread over Europe, South and North America and Asia. In the last decade it expanded to contain various aspects of health maintenance, overall wellness, prevention of illness and correction of the aging process withenhancement of features and improvement of visible deficiencies.

   Unfortunately, the “enhancement” and “improvement” have spiraled out of control replacing natural beauty with an amateur concept of over-improvement that resulted in antithesis of aesthetics. The abundant examples are all around us: oversized breasts, shapeless and disproportionate lips, protruding cheeks, pencil – shaped noses with upturned, “pinched” tips or a “shrink-wrapped” immobile foreheads with hyper-arched eyebrows.

  It is impossible to say what or who triggered this sub-culture that lingers on like a nightmare. What isknown, is that the rest of the world has followed more difficult trends, shifting their aesthetic forces into natural and artistic enhancements.

  The need for aesthetic services is constantly growing,  reflecting ones natural desire to look as good as possible. Unfortunately, the prevailing trends of facial aesthetics are being defined too frequently by those who have marginal understanding of true aesthetics.

    The physical ability to hold a pencil, brush, chisel, syringe, or laser hand-piece is a minor accomplishment in the scheme of aesthetic creation. However, the very next step, the ability to understand and properly assess the spatial relationships of target area, is what opens…….or shuts the door to the successful project.

  An “Artistic sense” is almost impossible to learn in full….. it is either a part of our perceptive process or not. If it is, the work is inspired and the job is well done….if it is not, one should think of it as notnecessarily a fault of the aesthetic practitioner per se  but  his/her failure to recognize it.

    But what if the practitioner doesn’t want to admit that his/her left brain dominates thus giving the aesthetic doctor all the gifts of scientific brilliancy but making him a poor artist?

   Nothing could better illustrate the point than an event that I witnessed during the 6th Anti-Aging Medicine World Congress in Paris in 2008.  This grand annual event is attended mostly by physicians from countries in Europe, South America and Asia, countries that have been well ahead in implementation of true aesthetics.

   As a part of the Congress, there are live presentations of the newest concepts, from laser procedures to implants and injection techniques.

One of the workshops, a non-surgical cheek augmentation with dermal fillers turned out, unexpectedly, to be one of the most educational and memorable presentations of the Congress.

The injector was a guest expert from the East Coast city in the US; the patient – model, a Frenchman in his early 40’s.

 After a brief introduction the expert began injecting the right cheek of the model.

 Two syringes later, before proceeding to left side, the presenter asked the audience for any questions regarding the injection technique.

  To his surprise several eager hands shot up into the air and the floor was given to an older gentleman, a French plastic surgeon. In his heavy accent, he asked the expert: “Doctor, could you please ask your model to smile?” The request was translated and the patient obliged with a suspicious , almost clownish smile.

  The audience gasped, some laughed, some murmured and the rest contemplated results in silence. The model smiled no more.

   The author of the question continued…:  “This is an unacceptable result for many of us; it’s unnatural, with disregard to proportions and any artistic or aesthetic values. I am sad to say but you would be banned from injecting this way in many countries”.

It was a tense moment to say the least, an embarrassing and humbling  moment for the patient AND the physician. It brought to realization the enormous divide of artistic perception between us here in the US and the rest of the world practicing Medical Aesthetics.

The event was suddenly amplified by the motto of the Congress:

                                                “LESS is MORE”.

In October 2009 issue of “Plastic and Reconstructive Surgery Journal I found the following article:

Less pain during injections for wrinkle-fighting facial fillers.

Less swelling afterwards.

Less time in the office waiting for anesthesia to take effect.

These are other benefits of a new injection technique that UT Southwestern Medical Center plastic surgeons are helping pioneer and are outlined in the October issue of Plastic and Reconstructive Surgery.  The procedure combines lidocaine with injections of facial fillers to instantly minimize the pain and allows plastic surgeons to begin the injection procedures without waiting for traditional anesthesia to take effect…

And so on…

The addition of anesthetics to dermal fillers is nothing new in the world.  In Europe, South America and Asia this method has been used for years and years.  Not anymore though, because the major filler companies pre-mix their fillers with Lidocaine which are available in variety of products.

I have been using this technique since our doors opened 2 years ago.  I was formally trained with advanced Botox injections in 2007 by an instructor who had been pre-mixing fillers with Lidocaine for at least a year.

Am I misunderstanding the word “pioneer”?